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NAPLEX BABY > Module 6: Chapters 47 to 60 > Flashcards

Module 6: Chapters 47 to 60 Flashcards

1
Q

Phases of the Menstrual Cycle: Follicular

A

each follicule in an ovary contains an oocyte. Follicle stimulating hormone (FSH) spurs follicle development by the end of the phase.
-the surge in estrogen causes luteinizing hormone and FSH to increase

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2
Q

Phases of the Menstrual Cycle: Ovulatory

A

the LH surge triggers ovulation 24-36 hrs later. Ovulation is the release of the egg from the ovary

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3
Q

Phases of the Menstrual Cycle: Luteal

A

the start of ovulation begins the luteal (last) phase, which lasts ~14 days, progesterone is dominant in this phase

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4
Q

what are some things to do for preconception health?

A

-increase folic acid (folate, vitamin B9) 400 mcg = 600 mcg when prego. folate deficiency can cause birth defects of the brain and spinal cord (neural tube defects)
-stop smoking, illicit drugs and alcohol
-keep vaccinations current

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5
Q

Drospirenone oral contraceptive

A

-progestin that is used in some COCs to reduce AEs commonly seen with oral contraceptives.
-it has a mild potassium sparing diuretic which decreases bloating

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6
Q

Progesterone only pills

A

-contain no estrogen and have 28 days of active pills
-prevent pregnancy by suppressing ovulation, thickening the cervical mucus to inhibit sperm penetration and thinning the endometrium
-needs good adherence: must be taken within 3 hours of the scheduled time
-safe in women who have migraines with aura

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7
Q

general tips for contraceptive names

A

-Lo: < 35 mcg of estrogen; less estrogen = less estrogenic SEs
-Fe: iron supplement is included
-24: shorter placebo time: 24 active + 4 placebo = 28 day cycle

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8
Q

Severe & rare AEs of estrogen (ACHES)

A

A: abdominal pain that is severe - can indicate a ruptured liver tumor or cyst, mesenteric or pelvic vein thrombosis, or the pain could be due to liver or gallbladder issue
C: chest pain- sharp, crushing or heavy pain can indicate a heart attack, SOB can indicate a PE
H: headaches- sudden and severe with vomiting or weakness/numbness on one side of the body can indicate a stroke
E: eye problem- blurry vision, flshing lights or partial/complete vision loss can indicate a blood clot in the eye
S: swelling or sudden leg pain- can indicate a DVT

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9
Q

BBW of hormonal contraceptives

A

BBW:
–> all estrogen-containing products (pils, patch, ring): do NOT use in women > 35 yrs old who smoke due to risk of serious cardio events
–> estrogen + progestin transdermal patch: do not use in women with a BMI > 30 kg/m2 (due to increased risk of thromboembolism) or dec effect (twirla)
–> Depo-Provera: loss of bone mineral density with long terms use
DO not use estrogen with these conditions:
-hx of DVT/PE, stroke, CAD
-hx of breast, ovarian or liver cancer
-severe headache or migraines with aura

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10
Q

drug interactions that DECREASE hormonal contraception efficacy

A

-abx (rifampin–> use back up method for 6 weeks after use, rifabutrin, rifapentine) strong inducers
-anticonvulsants (carbamazepine, oxacarbazepine, phenytoin, primidone, topiramate, lamotrigine)
-st johns wort
-smoking tobacco
-ritonavir

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11
Q

drug interactions with hormonal contraceptives: risks with hepatitis C tx

A

-Mavyret cannot be used with any formulation containing ethinyl estradiol due to the risk of liver toxicity
-with all new hep C drugs being dispensed to a pt using contraceptives

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12
Q

Drospirenone drug interactions

A

risk of increased potassium

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13
Q

Late or missed pills instructions

A

-start as soon as remembered
-if more than 1 COC pill is missed, back up contraception is required
-if missed pills are in the 3rd week- omit the hormone free week and start the next package of pills right away- back up contraception should be used for 7 days

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14
Q

Emergency contraceptives (3)

A

1) copper IUD: most effective, use within 5 days, lasts for up to 10 yrs
2) Ullipristal (Ella): more affective than plan B, (less effective > 195 lbs or BMI > 30), uses ASAP or 5 days
3) Levonorgestrel (plan B): less effective if > 165 lbs or BMI > 25, use ASAP/within 3 days, available OTC

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14
Q

infertility drugs act like endogenous hormones to trigger ovulation

A

-inc LH/FSH = ovulation (release of eggs)
-clomiphene acts as estrogen to inc LH/FSH = causes ovulation
-Aromatase inhibitors suppress estrogen to inc FSH = causes ovulation
-Gonadotopin drugs act as LH, FSH or hcg = causes ovualtion
-can trigger the release of multiple eggs and inc risk of multiple births

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14
Q

what vaccines are recommended for prego pts

A

-inactivated influenza
-single dose of Tdap

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15
Q

Teratogens in pregnancy: acne meds

A

-isotretinoin
-topical retinoids

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16
Q

Teratogens in pregnancy: antibiotics

A

-qionolones
-tetracyclines

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17
Q

Teratogens in pregnancy: anticoagulants

A

warfarin

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18
Q

Teratogens in pregnancy: Dyslipidemia, HF and HTN

A

-statins
-ACE
-ARBS
-aliskiren
-entresto

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19
Q

Teratogens in pregnancy: hormones

A

-estradiol
-progesterone
-raloxofene
-Duavee
-testosterone
-contraceptives

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20
Q

Teratogens in pregnancy: Migraine

A

-dihydroegotamine
-ergotamine

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21
Q

Teratogens in pregnancy: others

A

-hydroxyurea
-lithium
-methotrexate
-misoprostol
-NSAIDs
-Paroxetine
-Ribavirin
-Thalidomide
-Topiramate
-weight loss drugs
-valproic acid/divalproex

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22
Q

what is preeclampsia?

A

-complication of pregnancy that presents with elevated BP & evidence of organ damage (kidney/liver)
-if not treated, can lead to eclampsia which can lead to eclampsia - can lead to seizure/death
-only cure is delivery of baby

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23
Q

how do you prevent preeclampsia?

A

adding low dose ASA at the end of the firs trimester for women at risk (risk factors = DM 1 or 2, renal disease, hx of preeclampsia, chronic HTN)

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24
Q

Management in Pregnancy: morning sickness/M/V

A

-lifestyle: smaller frequent meals, water, avoid spicy foods
-pyridoxine (vit B6) +/- doxylamine
-RX: doxylamine/pyridoxine (Bonjesta, Diclegis)

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25
Q

Management in Pregnancy: GERD/Heartburn

A

-eat smaller, more frequent meals, not eating 3 hrs prior to sleep
-tums (if not working, can add on PPI or H2)

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26
Q

Management in Pregnancy: flatulence

A

simethicone (gasX, Mylicon)

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27
Q

Management in Pregnancy: Constipation

A

-inc fluid intake, inc fiber and physical activity
-fiber (psyllium, calcium polycarbophil, methylcellulose)
-docusate and polyphethylene glycol are used to prevent and treat constipation

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28
Q

Management in Pregnancy: Cold, cough, allergies

A

-1st line: cromolyn
-2nd line: 1st gen antihistamines: chlopheriramine and diphenhydramine
-allergy: budesonide and beclomethasone are preferred

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29
Q

Management in Pregnancy: Pain

A

-1st line: acetaminophen
-AVOID NSAIDs

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30
Q

Management in Pregnancy: Asthma

A

-budesonide
-rescue (inhaled albuterol)

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31
Q

Management in Pregnancy: HTN

A

-labetalol
-methyldopa
-nifedipine

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32
Q

Management in Pregnancy: DM

A

insulin is preferred
-metformine and glyburide

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33
Q

Management in Pregnancy: infections

A

-penicillins, cephalosporins, erythromycin and azithromycin are safe
–> vag funcgal: topical antifungals x 7 days (avoid fluconazole)
–> UTI: cephalexin 500 mg x7, ampicillin 500 mg x 7,
-last line = nitrofurantoin, bactrim during 1st trimester, NOT BE USED during the last 2 days of pregnancy

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34
Q

Management in Pregnancy: conditions needing anticoagulation

A

VTE:
–> tx: LMWH
–> proh: pneumatic conpression +/- LMWH
-warfarin is teratogenic (can be switched back after 13th week if has mechanical valve)

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35
Q

Management in Pregnancy: hypothyroidism

A

-levothyroxine (will require 30-50% dose increase)

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36
Q

Management in Pregnancy: hyperthyroidism

A

-graves disease: propylthiouracil
-methimazole also used

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37
Q

what meds should be avoided while breastfeeding?

A

-amphetamines
-amiodarone
-ergotamines
-lithium
-metronidazole
-phenobarbital
-statins

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38
Q

Factors that have osteoporosis risk: patient characteristics

A

-advanced age
-ethnicity (caus and asians at higher risk)
-family hx
-sex (females)
-low body weight

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39
Q

Factors that have osteoporosis risk: Medical diseases/conditions

A

-DM
-eating disorders
-GI disease (IBD, celiac disease, gastric bypass, malabsorption syndrome)
-hyperthyroidism
-hypogonadism in men
-menopause
-rheumatoid arthritis, autoimmune disease
-others: epilepsy, HIV/AIDS, parkinson disease

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40
Q

Factors that have osteoporosis risk: Lifestyle factors

A

-smoking
-excessive alcohol intake (3 drinks/day)
-low calcium intake
-low vit D intake
-physical inactivity

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41
Q

Factors that have osteoporosis risk: Medication

A

-anticonvulsants (carbamazepine, phenytoin, phenobarbital)
-aromatase inhibitors
-depo-medroxyprogesterone
-GnRH
-lithium
-PPIs
-Steroids
-thyroid hormone (in excess)
-loops, SSRIs, TZDs

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42
Q

osteoblasts

A

the cells involved in bone formation

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43
Q

osteoblasts

A

cells involved in resorption; they break down tissue in the bone

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44
Q

What is a T-score?

A

-it compares the pts measured BMD to the average peak BMD of a healthy, young, white adult of the same sex
-a DEXA measures BMD so a T-score can be determined
-T scores are negative: a score at or above -1 correkated with stronger (denser) bones, which are less likely to fracture

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45
Q

how. to interprete T- scores

A

Normal: > -1
Osteopenia: -1 to -24
Osterporosis: < -2.5

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46
Q

who should have BMD measured?

A

-women > 65 y/o
-men > 70 y/o
-younger patients at high risk for fracture

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47
Q

calcium role in OA:

A

-rec to take 1,000-1,200 mg elemental ca (do not exceed 500-600 mg/dose)
–> calcium carbonate: (tums)
-40% elemental calcium
-absoprtion: acid dependent
-must take with meals
–> calcium citrate (citracal)
-21% elemental calcium
-absorption: not acid-dependent
-can take with or without food

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48
Q

Vitamin D role in OA:

A

-required for caclium absorption
-deficiency = serum vitmain D < 25 ng/mL
–> treat deficiency with cholecalciferol (vit D3) OR Ergocalciferol (vit D 2)
- cholecalciferol: 125-175 mcg daily
-ergocalciferol: 1,250 mcg weekly

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49
Q

criteria for initiating treatment in osteoporosis

A

-T-score < -2.5 in the spine, femoral neck, total hip or 1/3 radius, OR
-presence of a fragility fracture, regardless of BMD

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50
Q

criteria for initiating treatment in osteopenia (high risk)

A

-low bone density (T score between -1 and -2.5) AND
-FRAX score indicated a 10-yr probability of a major osteoporosis-related fracture > 20% or a 10-yr hip fracture prob > 3%

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51
Q

Treatment of OA: Bisphosphonates

A

-1st line
-Alendronate (Fosamax) (preven: 5 mg qd, tx: 10 mg qd)
CI: hypocalcemia, inability to stand/sit upright for at least 30 mins
SEs: esophagitis, hypocal, GI effects (rare ones: atypical femur fracture, osteonecrosis of the jaw
-separate from calcium, antacids, iron and mag by at least 2 hrs
TX duration: 3-5 yrs in pts with a low risk of fracture

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52
Q

Treatment of OA: Injectable Bisphosphonates

A

-Ibandronate (Bonvia) 3 mg IV q 3 months
-Zoledronic acid 5 mg IV once yearly
CI: hypocalcemia
-monitor for renal impairment
*preferred if esophagitis is present

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53
Q

Treatment of OA: Raloxifene

A

-an estrogen agonist/antagonist (SERM that dec bone resorption) horse estrogen
BBW: inc risk of VTE and death due to stroke
CI: VTE, pregnancy
-SEs: hot flashes, edema, arthralgia, leg cramps

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54
Q

Treatment of OA: Calcitonin

A

-inhibits bone resorption by osteoclasts
-nasal spray ( 1 qd) or SC/IM: 100 u qd
Warnings: hypocalcemia, inc risk of malignancy, hypersensitivity to salmon-derived products

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55
Q

Treatment of OA: RANKL inhibitor, Denosumab (Prolia)

A

-prevents osteoclast formation= leads to dec bone absorption and inc bone mass- used in pts with high risk of fracture
-60 mg sc q 6 months
-CI: hypocalcemia, pregnancy
warnings: atypical femur fracture, osteonecrosis of the jaw
-SEs: HTN, fatigue, edema, dysnpea, headache, N/V, dec PO4

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56
Q

Treatment of OA: Romosozumab

A

-indicated for postmenopausal females w/ hx of an osteoporotic fracture or multiple risk factors - inhibits sclerostin, a protein that blocks bone formation- tx limited to 12 months
-BBW: inc risk of stroke, MI and cardio death
-CI: hypocalcemia

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57
Q

Treatment of OA: Raloxifene (Evista)

A

-alt to bisphosphonates if high risk of vertebral fractures
-increased risk for VTE and stroke
-can be used if low VTE risk or high breast cancer risk
SEs; vasomotor symptoms

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58
Q

Treatment of OA: Bazedoxifene/Estrogens (Duavee)

A

-can be used in women with an intact uterus for prevention of osteoporosis
-alsi used as tc for vasomotor symptoms
SE: increased risk of cancer

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59
Q

Hormone therapy for meno, health risk and appropriate use: estrogen

A

-most effective tx for vasomotor symptoms
-women with a uterus: use in combo with a form of progesterone- unopposed estrogens increases the risk of endometrial cancer
-associated w/ sig risk of VTE, stroke, breast cancer

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60
Q

Hormone therapy for meno, health risk and appropriate use: Progestin

A

-progestins can be given as part of a combination pill or as seperate tab (medroxyprogesterone)
-can cause mood disturbances, which may be intolerable; if taken intermittently, spotting can occur
-micronized progestins are considered to be dafer than synthetic progestins

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61
Q

Criteria for use of hormone therapy in menopause

A

-healthy, symptomatic women who are within 10 yrs of menopause, < 60 y/o and have no CI to use
-extending tx beyond 60 yrs may be acceptable if the lowest dose is used.
-consider QOL priorities and personal risk factors - pts with risk factors should use nonhormonal therapy: SSRIs, SNRIs, gaba or pregablin

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62
Q

local hormone therapy products

A

-17-beta estradiol: estrace, estring, vagifem, premarin

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63
Q

Systemic hormone therapies

A

-estradiol (Alora, climera)
-MPA
-Prometrium
BBW: endometrial cancer, dementia, inc risk of VTE, stroke, breast cancer
-CI: breast cancer, uterine bleeding, active VTE, pregnancy

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64
Q

SSRI for menopause: Paxil, paroxetine

A

-used for moderate - severe vasomotor symptoms

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65
Q

Ospemifene (Osphena)

A

-oral estrogen antagonist/agonist indicated for dyspareunia (painful intercourse) and moderate vaginal dryness
-should be used short term

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66
Q

Testosterone use: androgel and depo-testosterone

A

BBW: secondary exposure in kids
warnings: inc risk of breast cancer, prostate cancer, cardio events, VTE
SEs: inc appretite, acne, edema, hepatotoxicity, reduced sperm count

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67
Q

What are the key drugs that can cause erectile dysfunction?

A
  • alcohol
    -antidepressants (SSRIs, SNRIs)
    -antihypertensives (1st gen, cholrpromazine, prolactin-raising 2nd gen (risperidone, paliperidone))
    -BPH meds (finesteride, dutaseride, silodosin)
    -anticancer drugs (leuprolide, flutamide)
    -anticholerlinergics
    -H2RAs (climetidine, ranitidine)
    -nicotine
    -opioids
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68
Q

whar are the natural products that are used to treat ED?

A

-yohimbe
-L-arginine
-panax ginseng

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69
Q

PDE-5 inhibitors: Sildenafil (viagra)

A

-on demand dosing: 25-100 mg qd PRN (start at 50 mg, take 1 1/2 hr before sex)
-also used for pulmonary HTN
CI: do not use with nitrates or riociguat
Warnings: hearing loss, color discrimination, vision loss, hypotension, priapism
SEs: headache, fluching, dizziness,
-cna have decreased efficiacy if taken with a high fat or large meal

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70
Q

PDE-s Inhibitors: Tadalafil (Cialis)

A

-2.5-5 mg daily (on demand dosing: 5-20 mg daily PRN)
-lasts the longest “weekend pill”
CI: do not use with nitrates or riociguat
Warnings: hearing loss, color discrimination, vision loss, hypotension, priapism
SEs: headache, fluching, dizziness,
-crcl 30-50 : 5 mg prn, crcl < 30: 5 mg q 72 hrs

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71
Q

When do you reduce PDE-5 inhibitor doses?

A

> 65 y/o
using an alpha blocker
using a CYP3A4 inhibitor
severe renal or liver failure
*decrease dose by 50% (V: 25 mg, C: 5 mg)

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72
Q

PDE-5 inhibitor drug interactions

A

-absolute contraindication: using nitrates = extreme hypotension
-enhance the hypotensive effects of alpha 1 blockers
-alcohol can enhance hypotension
-moderate and strong CYP450 inhibitors (grapefruit juice, protease inhibitors, azole antifungals)

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73
Q

Aloprostadil (Prostagladin) for ED

A
  • a vasodilator that allows blood to flow into the cavernosal arteries, which then enlarges the penis
    -either injected into the penis of a pellet is inserted through the urethera
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74
Q

drugs for hypoactive sexual desire disorder: Fibanserin (Addyi)

A

-100 mg QHS (d/c if no benefits after 8 weeks)
-BBW: CI with alcohol, CYP3A4 inhibitors
Warnings: hypotension, suncope, CNS depression
SEs: dizziness, nausea, fatigue, insomnia, dry mouth
-avoid in pregnancy or if breast feeding

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75
Q

rugs for hypoactive sexual desire disorder: Bremelanotide (Vylessi) injection

A

-1.75 mg SC PRN, injected 45 min before sextual activity
CI: do not use with uncontrolled hypertension or known cardiovascular disease
Warnings: inc BP, dec HR after each dose
-avoid in pregnancy, effective contraception should ne used

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76
Q

what drugs can worsen BPH?

A

-centrally-acting anticholergics (bentropine)
-antihistamines
-decongestants
-phenothiazine
-TCAs
-caffeine
-diuretics
-SNRIs
-testosterone products

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77
Q

symptoms and complications of BPH

A

-hesitancy, interm. urine flow, straining or a weak stream of urine
-urinary urgency and leaking or dribbling
-incomplete emptying of the bladder

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78
Q

non-selective Alpha 1 blockers for BPH:

A

Doxazosin (Cardura), (XL version mau leave ghost pill in poop)
Terazosin
-should be given at bedtime to help minimize the initial “first dose” effect of orthostasis/dizziness

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79
Q

selective alpha blockers for BPH

A

-Tamsulosin (Flomax)
-Alfuzosin
-Silodosin (can cause retrograde ejaculation

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80
Q

Alpha 1 blockers class safety/SEs/Monitoring

A

Warnings: orthostatic hypotension/syncope, intraoperative floppy iris syndrome
SE: dizziness, fatigue, headache, abnormal ejaculation
-alpha blocker can be used for off label for bladder outley obstruction in women

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81
Q

alpha blocker drug interactions

A

-use caution when giving with PDE-5 inhibitors due to added hypotensive events
-silodosin cannot be used with strong P-gp inhibitors, such as cyclosporine
-alfuzosin can cause QT prolongation

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82
Q

5 alpha reductase inhibitors for BPH: finasteride (Proscar)

A

-F: 5 mg daily (Propecia used for alopecia)
CI: women of child-bearing potential pregnancy, children
Warnings: may increase risk of high grade prostate cancer
SEs: impotence, dec libido, ejaculation disturbances, breast enlargement and tenderness
–> prego women should not handle these meds
–> tx for 6 months may be required for mx efficacy

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83
Q

Phosphodiesterase-5 Inhibitors for BPH: Tadalafil (cialis)

A

-5 mg at the same time each day
CI: do not use with nitrates or riociguat
Warnings: hearing loss, vision loss, hypotension, priapism
SE: headache, flushing, dizziness, dyspepsia, back pain

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84
Q

what is urge incontinence?

A

a sudden and unstoppable urge to urinate. associated with neuropathy and often present in those with DM, strokes, dementia, parkinsons disease or multiple sclerosis

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85
Q

what is stress incontinence?

A

urine leaks out during any form of exertion as a result of pressure on the bladder

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86
Q

what is mixed incontinence?

A

combination of urge and stress incontinence

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87
Q

what is functional incontinence?

A

there is no abnormality in the bladder, but the pt may be cognitively, socially or physically impaired thus hindering access to a toilet

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88
Q

what is overflow incontinence?

A

leakage that occurs when the quantity of urine stored in the bladder exceeds its capacity. Often occurs without the urge to urinate

89
Q

risk factors for overactive bladder

A

-age > 40
-DM
-prior vaginal delivery
-obesity
-neurologic conditions
-drugs that increase incontinence (alcohol, cholinersterase inhibitors, diuretics, sedatives)

90
Q

non-drug treatments for overactive baldder

A

-1st line is behavioral therapy: bladder training, delayed or scheduled voiding, pelvic floor muscle exercises, fluid management

91
Q

Urge incontinence/mixed incontinence therapy

A

-1st line drugs include anticholinergics (oxybutynin) or beta -3 receptor agonist (mirabegron),
-onabotulinumtoxinA (Botox) has higher efficacy, but is not 1st line

92
Q

Anticholinergic drugs for OA

A

-oxybutynin (Ditropan) 5 mg PO BID
-Tolterodine (Detrol) 1-2 mg
-Solifenacin (Vesicare) 5-10 mg
CI: narrow angle glaucoma
Warnings: agitation, confusion, drowsiness, blurred vision
SE: dizziness and drowsiness, xerostomia, constipation

93
Q

Anticholinergic Side effect: Peripheral

A

-dry mouth
-dry eyes/blurred vision
-urinary retention
-constipation
-tachycardia

94
Q

Anticholinergic Side Effect: Central

A
  • sedation
    -dizziness
    -cognitive impairment
95
Q

Decreasing risk of dry mouth

A

-dry mouth is a major reason that pts fail to comply with anticholinergic tx
-choosing a tx that minimizes dry mouth can improve adherence:
–> try extended-release formulations (lower risk than IR formulation)
–> try oxybutynin gel or patch (lower risk than oral formulation)
–> beta-3 agonists have a lower incidence of dry mouth and can be helpful in pts who cannot tolerate anticholinergics
–> try non-drug options to help with symptoms: avoid mouthwashes with alcohol, use ice chips, water, sugar-free candy or gum

96
Q

Beta-3 agonists for OA use

A

-relax the detrusor muscle and increase bladder by activating beta-3 receptor (less dry mouth)
Mirabegron (Mybetriq): 25-50 mg daily
Vibegron (Gemtesa) 75 mg PO

Warnings: urinary retention in pts BPH, mirabegron can inc BP
-SEs: headache, constipation, diarrhea, dizziness
Monitoring: urinary symptoms, BP

97
Q

Nocturia Treatment

A

-Desmopressin (DDAVP) 0.2-0.6 mg at bedtime
-SL tablet (Nocdurna) females: 27.7 mcg, males: 55.3 mcg
BBW: hyponatremia
CI: fluid retention
warnings: do not use with nasal conditions
Monitoring: serum Na

98
Q

IV fluids: Crystalloids

A

-less costly and generally have fewer have fewer adverse reactions than colloids.
-balanced solutions may be preferred in certain disease states, such as sepsis, since the chloride load from a sodium chloride solution can be high enough to contribute to cellular injury, including renal damage
–> 5% dextrose (D5W)
–> 0.9% NaCl
–> Lactated Ringer’s

99
Q

IV Fluids: Colloids

A

-large molecules (typically protein or starch) dispersed in a solution; they primarily remain in the intravascular space and inc oncotic pressure.
-provide greater intravascular volume expansion than equal volumes of crystalloids, but are more expensive and have not shown a clear clinical benefit
–> albumin 5%, 2.5%

100
Q

Hyponatremia

A

-Na < 135 mEq/L normal
-not usually symptomatic until the sodium is <120 mEq/L
-symptoms most often result from cerebral edema and increased intracranial pressure, and can range from mild-moderate to sevre seizures, coma and resp arrest

101
Q

Hypotonic hypervolemic hyponatremia

A

caused by fluid overlaod (cirrhosis, HF, renal failure)
-diuresis with fluid restriction is the preferred tx

102
Q

Hypotonic isovolemic (euvolemic) hyponatremia

A

-can be caused by the syndrome of inappropriate antidiuretic hormone (SIADH)
-tx includes diuresis, restricting fluids and stopping drugs that can induce SIADH

103
Q

Hypotonic hypovolemic hyponatremia

A

-can be caused by diuretics, salt-wasting syndromes, adrenal insufficiency, blood loss, vom/diarrhea
-tx is to correct the underlying causes and stop the intake of hypotonic solutions

104
Q

How shoudl hyponatremia be corrected?

A

-correcting more rapidly than 12 mEq/L/24 hr can cause osmotic demilniation syndrome (ODS) or centeral pontine myelinolsis- which causes paralysis, seizures and death
-admin of desmopressin reduced water diuresis and can help avoid overcorrection

105
Q

Arginine vasopressin (AVP) receptor antagonists: treating SAIDH

A

-increase excretion of free water while maintaining sodium
-Tolvaptan (Samsca) 15 mg po daily (limited to < 30 d due to hepatotoxicity)
BBW: should be initiated and re-initiated in a hospital, overly rapid correction is associated with ODS
Warnings: hepatoxicity
SE: thirst, nausea, dry mouth, polyuria
Monitoring: rate to Na increase

106
Q

Hypernatremia

A

Na > 145 mEq/L is associated with a water deficit and hypertonicity
-hypovolemic hypernatremia is caused bt dehydration, vomiting or diarrhea and is treated with fluids
-hypercolemic hypernatremia is caused by intake of hypertonic fluids and is treated with diuresis
-Isovolemic (euvolemic) hypernatremia is frequently caused by dm insipidus, which can dec antidiuretic hormone (ADH), treated with desmopressin

107
Q

IV potassium

A

-can be fatal id administered undiluted or via IV push
-when hypokalemia is resistant to tx, serum magnesium should be checked
-mag is needed for K uptake- replace first when both hypokalemia and hypomagnesemia are present

108
Q

IV IG (gammagard, Gammunex-C, Octagam)

A

-given as a plasma protein replacement therapy for immune-deficient pts who have decreased or abolished antibody production abilities
BBW: acute renal dysfunction can occur, thrombosis
SEs: infusion reaction, renal failure or blood dyscrasias
–> pts should be asked about past IVIG infusion, a slower titration and premedication my be needed

109
Q

Dopamine Dosing

A

Low (renal): 1-4 mcg/kg/min (dopamine-1 agonist)
Medium: 5-10 mcg/kg/min (beta-1 agonsit)
High: 10-20 mcg/kg/min (alpha-1 agonist)

110
Q

Epinerprine MOA

A

-alpha-1
-beta-1
-beta-2 agonist
should be used IV push: 0.1 mg/mL
IM: 1 mg/mL

111
Q

Norepinephrine MOA

A

-alpha-1 agonist activity > beta-1 agonist activity

112
Q

Vasopressin MOA

A

vasopressin receptor agonist

113
Q

Vasopressors class Safety/SE/monitoring

A

BBW: dopamine and NE - vesicants when administered IV; treat extravasation with phentolamine
SEs: arrhythmias, tachycardia, nescrosis, bradycardia (phenyl), hyperglycemia (epin)
Monitoring: MAP
–> all vasopressors should be administered via central line

114
Q

Vasodilator: Nitroglycerin

A

-used when there is active MI or uncontrolled hypertension, limited to 24-48 hrs due to tachyphylaxis
-low dose = venous vasodilator, high dose = arterial
CI: SBP < 90, use with PDE-5 inhibitor
SE: headache, tachycardia, tachyphylaxis
-requires a non-PVC container (glass, polyolefin)

115
Q

Vasodilator: Nitroprusside (Nipride)

A

-has equal arterial and venous effects)
[NOT used in active MI (steals the blood) has better BP effect than nitro, metabolism results in thiocyanate and cyanide formation = toxicity]
(hydroxyocobalamin can be admin to reduce the risk of thiocyanate toxicity, sodium thiosulfate + sodium nitrite is used for cyanide toxicity)
BBW: cynaide, hypotension - should be diluted w/ D5W
SE: heachadem tachycardia, thiocyanate/cyanide toxicity
–> requires light protection, use only clear solutions to admin, a BLUE color indicated cyanide (DO NOT USE)

116
Q

Inotropes: Dobutamin & Milronine

A

-increase the contractility of the heart
D: beta-1 agonsit that inc HR and the force of myocardial contraction = inc CO
M: selective phosphodiestrase-3 inhibitor in cardiac and vascular tissue, produces inotropic effects with sig vasodilation
–> should only be used when BP is adequate b/c they produce vasodilation

117
Q

General principles for treating septic shock

A

-target a mean arterial pressure (MAP) of > 65 (MAP = [(2 x DBP) + SBP]/3
-fill the tank: optimized preload with IV crystalloids (LR)
-squeeze the pipe and kick the pump: alpha-1 agonist activity (peripheral vasoconstriction) to inc SVR, beta-1 agonist activity to inc myocardial contractility and CO

(broad spectrum abx and IV crystalloids, can use NE if needed)

118
Q

Common causes of ICU infections : Mechanical ventilation

A

-called respirators, air flows into the trachea through an endotrachial tube (ET) places through the mouth or nose.
–> inc time on ventialator = inc risk of infection (including lung)
-pseudomonas thrive in moist air in ventalators

119
Q

Common causes of ICU infections: Indwelling urinary catheter

A

inc time on foley = inc risk of infection

120
Q

Treating acute decompensated heart failure

A
  • pts with edema, JVD and/or ascites = volume overload –> loop diuretics, vasodilators can be added (NTG, nitro)
  • pts with dec renal function, AMS and/or cool extremities = hypoperfusion –> inotropes (dobutamine, milrinone), can add vasopressor if pt becomes hypotensive (dopa, NE, phenyl)
    -pt experiences BOTH volume overload and hypoperfuson –> combo og agents
121
Q

Agitation/sedation meds in ICU: Dexmedetomidine (Precedex)

A

-alpha 2 adrenergic agonist
SE: hypo/hypertension, bradycardia, dry mouth, nausea, constipation
-monitor: BP,HR, sedation scale
–> does not require refrigeration
–> duration of infusion should NOT exceed 24 hrs
–> use for sedation in intubated and non-intubated pts

122
Q

Agitation/sedation meds in ICU: Propofol (Diprivan)

A

-short acting general anesthetic
CI: hypersensitivity to egg, soy
SE: hypotension, apnea, hypertriglyceridemia, green urine/hair/nails, propofol-related infusion syndrome
Monitor: triglycerides
–> shake well
–> potential for bacterial growth; discard vial and tubing within 12 hrs of use
–> oil in water emulation provides 1.1kcal/ml

123
Q

Agitation/sedation meds in ICU: Lorazepam (ativan)

A

-injection is formulated in propylene glycol; total daily dose as low as 1 mg/kg/day can cause propylene glycol toxicity (ARF)

124
Q

Agitation/sedation meds in ICU: Midazolam (Versed)

A

benzo
-BBW: resp depression
-CI: do not use with potent CYP3A4 inhibitors
SE: hypotension
Monitoring: BP, HR, RR, sedation scale
–> can accumulate in obese pts and renal impairrment

125
Q

Risk factors for development of stress ulcers

A

-mechanical ventilation > 48 h
-Coagulopathy
-sepsis
-traumatic brain injury
-major burns
-acute renal failure
-high dose systemic steroids

126
Q

Commonly used anesthetics

A

Local: lidocaine (xylocaine)
Inhaled: Desflurane (Suprane), sevoflurane
Injectable: Bupivacaine (Marcaine), Ropivacaine (Naropin)

127
Q

Neuromuscular Blocking Agents: depolarizing = Succinylcholine (Anectine, Quelicin)

A

-short acting, fast onset (30-60sec)
-binds to and activated the ACh receptors and desensitizes them
-reserved for intubation and is not used for continuious neuromuscular blockade.
-has been associated with causing malignant hyperthermia

128
Q

Neuromuscular Blocking Agents: non-depolarizing (5)

A

-bind aCh receptor, blocking the actions of endogenous ACh- pts cannot breath, move or blink
–> Atracurium: short t1/2, intermediate-acting, hofmann elim
–> Cisatracurium: short t1/2. interm-acting, hofmann
–> Pancuronium: long acting, can accumulate in renal/hepatic dysfunction, inc HR
–> Rocuronium: interm
–> Vecuronium: interm, can accumulate

129
Q

Hemostatic agents: Tranexamic acid (Cyklokapron)

A

-inhibits fibrinolysis or enhancing coagulation
SE; vascular occulusion, thrombosis, retinal clotting
–> oral is approved for heavy menttrual bleeding, injection approved for hemophilia

130
Q

Hemostatic agents: Recombinant Factor VIIa (NovoSeven RT)

A

-inhibits fibrinolysis or enhancing coagulation
BBW: risk of thrombotic events
–> FDA approved for hemophilia and factor VII deficiency

131
Q

When to seek urgent care for a child

A

-age <3 m: temp of 100.4/38 (rectal)
-age 3-6 m: temp 101/38.3 (rectal)
-age > 6 m: temp 103/39.4 (rectal)
-ant cough/cold that worsens or does not improve in several days
-unusual, severe pain
-blood in stool or urine
-inability to sleep or drink
-rash that looks severe or rash w/ fever
-abrasions/cuts that are dirty or deep
-limping of unable to move extremity
-seizures

132
Q

what drugs can help the patent dutuc arterious in new born heart to close?

A

NSAID- IV indomethacin or ibuprofen) by blocking the prostaglandins that keep the PDA open
–> NSAIDs should not be used in 3rd trimester b/c they can cause the PDA to close prematurely

133
Q

Select OTC products for infants: Fever (Acetaminophen)

A

-10-15 mg/kg/dose every 4-6 hr (max 75 mg/kg/day)
–> most oral formulations are 160mg/5ml

134
Q

Select OTC products for infants: Fever (Ibuprofen)

A

-5-10 mg/kg/dose every 6-8 hrs (max 40 mg/kg/day)
–> infant drops = 50 mg/1.25 ml
–> childrens suspension = 100 mg/5 ml
**indicated for infants 6 months and UP

135
Q

Select OTC products for infants: Intestinal gas (Simethicone)

A

-20 mg 1-4 times/day PRN
–> adminster after meals and at bedtime for mild gas
–> shake drops, can mix with water, formula or other liquids

136
Q

Select OTC products for infants: Nasal dryness/congestion (saline solution)

A

2-6 drops per nostril PRN

137
Q

Select OTC products for infants: Constipation

A

-PEG (miralax) : age > 6 mon: 0.4 mg/kg, max 17 gram, dissolve in 4 oz of water
-Glycerin supp: 1 ped supp per dose

138
Q

Bacterial meningitis pathogens: < 1 month y/o

A

-streptococcis agalactiae (group B strep), E. coli, listeria monocytogens, Klebsiella
Empiric tx: ampicillin + cefotaxime or ampicillin + aminog (gentamicin)

139
Q

Bacterial meningitis pathogens: 1-23 month y/o

A

-streptooccus pneumoniae, Neisseria meningitidis, S, agallactiae, Haemophilus influenzae, E. coli
Empiric TX: vanco + 3rd gen ceph (ceftriaxone or cefotaxime)

140
Q

Bacterial meningitis pathogens: > 2 y/o

A

-N. meningitidis, S. pneumoniae
Empiric TX: vanco + 3rd gen ceph (ceftriaxone or cefotaxime)

141
Q

Who should recieve Palivizumab (Synagis)? (vaccine for RSV)

A

-dosed monthly at 15 mg/kg per dose given via IM
*in the first yr of life:
–> premature infants born at < 29 weeks gestation
–> premature infants born < 32 weeks gestation eith chronic lung disease who are < 12 months og age
–> infants < 12 months of age with certain heart conditions

142
Q

Treatment of Croup

A

-viral infection caused by inflammation of upper airway
–> signs: inspiratory stridor, barking cough, and hoarseness (most common in children < 6 y/o)
-systemic steroids (dexamethasone 0.6 mg/kg dose x 1)

143
Q

Treatment for nocturnal enuresis: Desmopresson (PO)

A

-synthetic analog of antidiuretic hormone - will decrease nocturnal urine production
-start at 0.2 mg PO QHS, can titrate to 0.6 mg QHS
CI: hyponatremia
SE: headache
–> limit fluids starting 1 hr before dose and until the next am

144
Q

Drugs to avoid in peds

A

CI:***
-codeine in age < 12
-Tramadol in age < 12
-Promethazine in age < 2
-Ceftriaxone in neonates (0-28 days)
NOT REC:
- aspirin in children and teenagers
-quinolones ( AE on bones and cartilage)
-tetracylcines in age < 8 (stain teeth)
-OTC teeth medications contianing benzocaine in age < 2
-OTC cough and cold preps in age <2 yrs

145
Q

what are 2 primary toxins that can lead to accidental overdose in children?

A

-Iron and acetaminophen

146
Q

Vaccine preventable disease in childhood: Measles

A

-Koplick spots in mouth, maculopapular rash
-transmission is airborne
-Prevention: MMR vaccine

147
Q

Vaccine preventable disease in childhood: Mumps

A

-swollen salivary glands
-Prevention: MMR vaccine

148
Q

Vaccine preventable disease in childhood: Rubella

A

-fever, rash, swollen glands
-Prevention: MMR vaccine

149
Q

Vaccine preventable disease in childhood: Polio

A

-nerve damage, cannot walk
Prevention: IPV vaccine

150
Q

Vaccine preventable disease in childhood: Pertussis

A

-“whoop” sounding cough
Prevention: DTaP vaccine

151
Q

Vaccine preventable disease in childhood: Rotavirus

A

-diarrhea, fever, vomiting
Prevention: RV vaccine

152
Q

Vaccine preventable disease in childhood: Chicken pox

A

itchy, rash, fever
Prevention: varicella vaccine

153
Q

What is cystic fibrosis?

A

-incurable, hereditary disease cause by a mutation in the gene for the protein CFTR. –> causes thick, viscous secretions in lungs, pancreas, liver and intestine
-average lifespan is 35-40 yrs, diagnosed by age 2 (new born screenig at 2-3 days, sweat chloride test, high = CF)
-symptoms: salty skin, poor growth/weight gain, coughing, SOB

154
Q

inhaled meds for CF pt: order is IMPORTANT**

A

1) inhaled bronchodilators (albuterol) = opens the airway
2) hypertonic caline (Hypersal) = mobilizes mucus to improve airway clearance
3) Dornase alfa (Pulmozyme) = decreases viscosity of (thins) mucus to promote airway clearance
4) chest physiotherapy = mobilizes mucus to improve airway clearance
5) Inhaled abx = controls airway infection

155
Q

Treatment for lung complications and infection in CF: airway clearance therapies (inhaled)

A

options: albuterol, hypertonic saline, Dornase alfa*
–>DA: works by degrading extracellular DNA in the lungs to decrease viscosity of mucus
CI: hypersensitivity to chinese hamster ovary products
SE: chest pain, fever, rash
-store ampules in the fridge, protect from light, do not mix with any other drug in the nebulizer

156
Q

Treatment for lung complications and infection in CF: abx (inhaled) to target Pseudomonas aeruginosa: Tobramycin (TOBI)

A

-age > 6y/o
SE: ototoxicity, tinnitus, voice alteration, mouth and throat pain
–> give for 28 days on and 28 days off cycle
-do not mix with other drugs in neb

157
Q

Whats in the name?: Lungs: Dornase alfa/ Pulmozyme

A

-Enzyme!
-breaks down DNA strands into smaller pieces, thinning the mucus to make it easier to cough up

157
Q

Treatment for lung complications and infection in CF: abx (inhaled) to target Pseudomonas aeruginosa: Aztreonam (Cayston) and Azatam (IV)

A

-age > 7 yrs, 75 mg via neb
SE: allergic reactions, bronchospasm, fever, wheezing, cough, chest discomfort
–> give for 28 days on, 28 days off
- do not mix with other drugs in neb

157
Q

reatment for lung complications and infection in CF: oral obx ( to dec inflammation and exacerbations) Azithromycin (Zithromax)

A

-age > 6 yrs
SE: tinnitus, nausea, risk of QT prolongation

158
Q

Whats in the name?: GI tract: Pancrelipase

A

-lipase, protease and amylase–> needed to break down fats, proteins and starches

159
Q

Pancreatic enzyme products in CF tx: Pancrelipase (creon, viokace, zenpep)

A

age < 1 yr: varies
age 1-3 y: lipase 1000u/kg/meal
age > 4 y: lipase 500 u/kg/meal
MAX: < 2500 u/kg/meal
SE: abdominal pain, flatulance, nausea

160
Q

Common issues with pancreatic enzyme products

A

-pancreatic enzyme replacement helps pts with CF digest food, maintain weight and improve nutrient absorption
-PEP formulations are not interchangable
-Viokace is the only PEP that is a tab, must be given with a PPI
-all others are capsules: do not cruch, or chew
-take PEPs before or with all meals and snacks, high-fat meals may require higher doses (use 50% of mealtime dose with snacks)
-protect from moisture, dispense in original containers (exceptions: zenpep and some creon strengths), do not refigerate

161
Q

Induction Immunosuppression: Antithymocyte Globulin (Atgam- equine, Thymogloblin- rabbit)

A

-binds to antigens on T-lymphocytes and interferes with their function
-BBW: anaphylaxis
-SE: infusion reaction
–> premedicate to lessen infusion-related reactions

162
Q

Induction Immunosuppression: IL-2 receptor agonists : Basiliximab (Simulect)

A

-20 mg iV on the day of transplant (day 0), then repeat dose on post operative day 4
SE: inc BP, fever, stomach upset/n/v

163
Q

What is used for maintenance immunosuppression in transplant?

A

-a calcinerurin inhibitor- cyclosporine or tacrolumus (this is 1st line)
-an anti proliferative agent such as mycophenolate (1st line) or azathioprine
-w/ or w/o steroids

164
Q

Calcinerurin-inhibitors: Cyclosporine (Gengraf, Neoral, Sandimmune)

A

-suppresses cellular immunity by inhibiting T-lymphocyte activation
BBW: nephrotoxicity, inc risk of lymphoma, malignancies, skin cancer
SE: inc BP, nephropathy, hyperkalemia, hypomag, QT prolongation
Monitor: trough, serum electrolytes, renal function, BP,

165
Q

Calcinerurin-inhibitors: Tacrolimus (Prograf)

A

-1st line!! suppresses cellular immunity by inhibiting T-lymphocyte activation
BBW: inc risk of infections
SE: inc BP, nephrotoxicity, inc BG, hyperkalemia, QT prolongation
Monitor: serum electrolyyes, renal function, LFTs, BP, blood glucose

166
Q

Anti-proliferative agents: Mycophenolate Motetil (CellCept). Mycophenolic Acid (Myfortic)

A

-inhibit T- and B-lymphocyte proliferation by altering purine nucleotide synthesis
BBW: inc risk of infection, lymphoma, skim malignancies
SE: diarrhea, GI upset
–> not interchangeable (CellCept 500 mg = Myfotic 360 mg)
–> CellCept IV is stable in D5W only
–> decreases efficacy of oral contraceptives

167
Q

Mammalian target of rapamycin (mTOR) kinase inhibitors:

A

-Everolimus (Zortress) –> do not use within 30 days of transplant
-Sirolimus (rapamune) –> impaired wound healing

168
Q

What drugs to use for induction Immunosuppressants in transplant

A

-Basiliximab, an interleukin (IL-2) receptor antagonist
-Antithymocyte globulin in pts at higher risk of rejection
-high dose IV steroids

169
Q

What drugs to use for maintenance immunosuppressants in transplant

A

-the CNIs (tacrolimus then cyclosporine)
–> belatacept as alt to a CNI
-adjuvant medications given with a CNI (to achieve adequate immunosuppression while decreasing the dose and toxicity of the individual agents
–> antiprolifertave agents (mycophenolate or azathioprine)
–> mTOR inhibitors (everolimus or azathioprine)
-steroids at lower or tapering doses

170
Q

Boxed warnings for transplant drugs

A

-infection risk: suppress the immune system
-cancer risk

171
Q

Vaccine - preventable illness in transplant recipients

A

-influenza (inactivated, not live) annually
-pneumococcal vaccines in adults > 19 yrs: PCV20 x1, PCV15 x1 followed by PPSV23 x1 8 weeks later
-varicella vaccine

172
Q

Key drugs that can cause weight gain

A

-antipsychotics (clozapine, olanzapine, risperidone, quetiapine)
-DM drugs (insulin, sulfonylureas, meglitinides, thiazids)
-divalproex/valproic acid
-gabapentin/pregablin
-lithium
-mirtazapine
-steroids
-TCAs
-hypothyroids

173
Q

Select drugs/conditions that can cause weight loss

A

-ADHD drugs
-bupropion
-GLP-1 (-tide)
-pramlintide
-Roflumilast
-SGLT2 (-flozin)
-Topiramate
-Tirzepatide
-Conditions: hyperthyroidism, celiac disease, inflammatory bowel disease

174
Q

Rx weight loss drugs to avoid in: HTN

A

-contrave: contraindicated in ppl with uncontrolled BP (contains bupropion)
-caution with Qsymia: monitor HR (contains phentemine)

175
Q

Rx weight loss drugs to avoid in: Depression

A

-Contrave: suicide risk (contains bupropion)

176
Q

RX weight loss drugs to avoid in: seizures

A

-Contrave: lowers seizure threshold (contains bupropion)
caution with Qsymia: must taper off slowly if used (contains topiramate)

177
Q

Rx weight loss drugs to avoid in: taking opioids

A

-Contrave: blocks opioid receptors (contains naltrexone)

178
Q

Weigh loss medication: Phentermine/Topiramte ER (Qsymia)

A

P: sympathomometic (stimulant): release of NE stimulates the satiety center which dec appetite
T: inc satiety and dec appetite, possibly by inc GABA, blocking glutamate receptors and/or inhibition of carbonic anhydrase
CI: glaucoma, pregnancy (REMS due to teratogenic risk)
SE: tachycardia, insomnia, vision problems
–> taper off due to seizure risk

179
Q

Weight loss medication: Naltrexone/Bupropoin (Contrave)

A

N: dec food craving
B: dec appetite
CI: pregnancy, chronic opioid use, uncontrolled HTN, seizures, use of MAOi within 14 days
–> fatty food increases drug levels: do not take with high-fat meal

180
Q

Weigh loss medication: GLP-1 Liraglutide (saxenda) and Semaglutide (wegovy) [ozempic and rybelsus for DM]

A

BBW: risk of thyroid c-cell carcinoma
CI: personal or fam hx of medullary thyroid carcinoma
warnings: pancrestitis, hypoglycemia
SE: nausea
–> may need to decrease insulin or sulfonylurea/meglitinide doses to dec risk of hypoglycemia

181
Q

Weight loss medications: Lipase inhibitors- Orlistat (Xenical, Alli- OTC)

A

-dec absorption of dietray fat by ~30%
CI: pregnancy
Warnings: liver damage, inc urinary oxalate/kidney stones
SE: GI, farts w/ dischage, fatty stools
–> take vit A,D,E,K and beta carotene at bedtime
–> must be used with a low-fat diet

182
Q

Weight loss medications: Phentermine (Adipex-P)

A

-appetite supp: release NE stimulates the satiety center which dec appetite
CI: cardiovascular disease, hyperthyroidism, glaucoma, pregnancy
SE: tachycardia, agitation, inc BP
–> use short term, up to 12 hrs

183
Q

Bariatric surgery for weight loss

A

-guidelines rec for adults with BMI > 40 kg/m^2 or with a BMI > 35 with an obesity- related condition

184
Q

how to treat an acetaminophen overdose?

A

-antidote = N-acetylcysteine (NAC)
–> glutathione precurser
–> administered IV or orally

185
Q

NSAID BBWs

A

-GI risk: inc the risk of GI bleed and ulceration
-CV risk: can inc the risk of MI and stroke (all non-selevtice NSAID except aspirin)
-CABG Surgery: NSAIDs use is CI after this, antiplatelet therapy (Apirin) is rec

186
Q

SEs of NSAIDs

A

-can decrease renal clearance
-inc blood pressure
-cause premature closure of the ducta arteriousus, do NOT use in 3rd trimester
-nausea
-photosensitivity

187
Q

NSAIDs and the Ductus Arteriosus*

A

-before birth the DA connects the pulmonary arter to the aorta, allowing oxygenated blood to flow to the baby, by bypassing the immature lungs
–> do NOT use NSAID in the 3rd trimester of pregnancy- can prematurely close the DA
-after birth, the DA should close on its own,
–> IV NSAIDs (Indomethacin, ibuprofen) can be used within 14 days after birth to close a DA

188
Q

Non-aspirin NSAIDs (COx-1, and COX-2 non selective)

A

–> all have GI risk, CV risk, and risk in post-operative CABG
-Ibuprofen (Advil, caldolor, Motrin): limit self-tx to 10 days, can cause SJS/TENS
-Indomethacin (Indocin): high risk for CNS effects
-Naproxen (Aleve): can be dosed BID
-Ketorolac (Toradol): MAX conbined duration IV/IM and PO = 5 days

189
Q

Cox-2 selective NSAIDs

A

-lower risk for GI complications, inc risk of MI/stroke, same risk for renal complications
-Celecoxib (Celebrex) : CI with sulfonamide allergy, highest COX-2 selectivity
-Diclofenac (voltaren) BBW: avoid in femals of childbearing potential (misoprostol is used to replace the gut-protective prostaglanidins to dec GI risk
-Meloxicam (Mobic)

190
Q

Salicylate NSAIDs

A

-Aspirin/Acetylsalicylic Acid (Ascriptin, Bufferin, Ecotrin)
–> avoid in children and teens with any viral infection due to potential risk of Reye’s syndrome
SE: PPIs may be used to protect the gut
-salicylare overdose can cause tinnitus

191
Q

NSAID drug interactions

A

-additive bleeding risk
-NSAIDs can inc levels of lithium and methotrexate

192
Q

Opioids boxed warnings

A

-addiction, abuse and misuse can lead to overdose and death
-respiratory depression
-use of opioids and benzo with other CNS depressants, including alcohol can cause death
-Morphine ER caps, Nucybnta ER, oxymorphone ER and hydrocodone ER caps: do not consume alcohol
-crushing, dissolving or chewing the long-acting products can cause delivery of potentially fatal dose
-life-threatening neonatal opioid withdrawal can occur with porlonged use during pregnancy

193
Q

opioids and non-cancer pain

A

-opioids are not first line for chronic pain tx
–if using opioid, start with immediate release: start low and go slow
– evlauate risk factors
–use adjunctive meds to enable a lower opioid dose
–avoid bezos

194
Q

opioid allergy

A

-codeine: hydrocodone, oxycodone
-Morphine: hydromorphone, oxymorphone
-Buprenorphine: herion

195
Q

Opioid-induced respiratory depression risks

A

OIRD risk factors:
-hx of previous overdose
-substance use disorder
-using large doses (> 50 mg morpine)
-use w/ benzos, gabapentin, or pregablin
-comorbid illness, sich as resp or psychiatric disease
–> naltrexone should be readily available to pts with elevated risk for ORID

196
Q

Opioid-induced Constipation

A

-opioids reduce GI tract peristalsis, making it difficult to have a bowel movement
-OIC does not improve over time without tx: it must be anticipated and treated
–> stimulant (senna, bisacodyl) or osmotic (polyethylene glycol) laxatives are the typical first line
-if laxitives are not sufficient, PAMORAs can be used
–> lubiprostone can be used following a trial of laxatives

197
Q

TX of opioid-induced constipation: PAMORAs

A

-block opioid receptors in the gut to reduce constipation w/o affecting analgesia (only affective when constipation is secondary to use of an opioid)
–Methylnaltrexone (Relistor) : only for pts who have failed OTC laxatives
–Naloxegol (Movantik)- d/c all laxatives prior to use

198
Q

TX oc opioid-induced constipation: Chloride channal activator

A

Lubiprostone (Amitiza)

199
Q

Opioid over dose management

A

S&S: extreme sleepiness, slow or shallow breathing, fingernails or lips turning blue or purple, extremely small pupils, slow heartbeat and/or blood pressure
–> give naloxone and call 911
-narcan: nasal spray, slower onset of action than injection (naltrexone)

200
Q

drugs for opioid use disorder:

A

-bupernorphine (C-3)
-methadone

201
Q

oral adjuvants for neuropathic pain

A

-gabapentin (Neurontin)
-pregablin (lyrica)
-Carbamazepine (tegretol)
-amitriptyline
-duloxetine (cymbalta)

202
Q

oral adjuvants for musculoskeletal pain

A

-baclofen (Lioresal)
-cyclobenzaprine (Amrix, Fexmid)
-tizanidine (zanaflex)
-carisoprodol (soma)
-methocarbamol (Robaxin)

203
Q

Topical adjuvants for musculoskeletal pain

A

-lidocaine
-lidocaine 5% (Lidoderm)
-capsaicin (zostrix,) - dec substance P
-methyl salicylate (bengay, icyhot)
-trolamine (aspercreme)

204
Q

Common Migraine Triggers

A

-hormonal changes in women: flunctuations in estrogen, progestrin only pills are rec for migraine with aura due to stroke risk with estrogen-containg pills
-foods: alcohol, cheeses, chocolate, aspartame, overdose of caffeine, MSG, salty foods and processed foods
-stress
-sensory stimuli: bright lights, sun glare, loud sounds and certain scents
-changes in wake-sleep patterns
-changes in environment

205
Q

how to make a diagnosis of migraine

A

When an adult has at least 5 attacks fulfilling:
- headaches last 4-72 hrs and recur sporadically
-headaches have > 2 of the following characteristics: unilateral location, pulsating, mod-severe pain and aggravated by routine physical activity
-one of the following occurs: nausea/vomiting, photophobia, and phonophobia (sensitivity to sound)

206
Q

acute drug tx of migraine

A

OTC: acetaminopen, aspirin, advil, naproxen, excedrin migraine
RX: NSAIDs, triptans, CGRP receptor antagosnits

207
Q

Triptans used for migraine tx

A

-vasodilator cranial blood vessels, inhibit neuropeptide release and decrease pain transmission, 1st line for acute tx–> take at the first sign of headache (all have tablet formualtion)
– Rizatreptan (Maxalt-MLT) ODT
– Sumatriptan Nasal, injection
– Imitrex
– Onzetra Xsail
– Zolmitriptran (Zomig) ODT, nasal

208
Q

Triptan class safety/SE/Monitoring

A

CI: cerebrovascular disease, uncontrolled HTN, ischemic heart disease
Warning: inc blood pressure, serotonin syndrome
SE: paresthesia, tripatan sensations (pressure or heaviness in the chest or pressure in the neck region)
–> all SC injections are preferred in lateral thigh or upper arm, protect from light

209
Q

Triptan drug interactions

A

-risk of serotonin syndrome
-Suma, riza and zolmi are CI with MAOi (or within 2 weeks of stopping)

210
Q

Migraine tx: Ergotamine drugs

A

-nonselective agonist of serotonin receptors causes cerebral vasoconstriction, in pts who do not find benefit with a triptan, ergotamine is generally used next
–> Dihydrogotamine (DHEA, Mogranal): injection/nasal spray
BBW: use with CYP3A4 inhibitors
CI: uncontrolled HTN, ischemic heart disease, pregnancy

211
Q

Migraine TX: CGRP receptor antagonsits

A

-contribute to vasodilation and neurogenic inflammation in the pathogenesis of migraines; blocking the CGRP receptor helps reduce or eliminate migraine pain

–> Ubrogeapant (ubrelvy): approved to treat acute migraine attacks
–> rimegepant (Nurtec): approved to prevent and treat acute migraine attacks

212
Q

Prophylactic drug treatment of migraine

A

-BBs (propranolol, meto tat, meto succ, timolol)
-Antieliptics (topiramate, valporic acid)
-CGRP receptor antagonsits (atogepant, epitinezumba, erenumab, nurtec)
-antidepressants (amitriptyline)
-monophasic OCs, NSAIDs or a triptan (frova, nara) can be started prior to menses and continued for 5-7 days

213
Q

Botulimun toxin for migraine tx

A

-botox injections are used from prophylaxis
chronic migraines only (> 15 headache days per month)

214
Q

Drugs that increase uric acid (inc risk for gout)

A

-aspirin, lower doses
-clacineurin inhibitors (tacrolimus and cyclosporine)
-diuretics (loops or thiazides)
-niacin
-pyrazinamide
-select chemotherapy
-select pancreatic products

215
Q

Gout treatment basics

A

Treat acute pain with anti-inflammatory drugs:
- colchicine
-steroids
-NSAIDs
Treat chronically to prevent future attacks:
-XOI: allopurinol (preferred) or febuxostat
If XOI didnt work well enough and UA remins > 6:
-add on probenecid or lesinurad to daily XOI
-replace the XOI with IV pegloticase (Krystexxa)

216
Q

Acute Gout Attack Therapy: Colchicine (Colcrys)

A

CI: P-gp or strong CYP3A4 inhibitors with renal and/or hepatic imparment
Warnings: myelosuppression, inc myopathy risk
SE: diarrhea, nauseam myopathy, neuropathy
–> start within 36 hrs of symptom onset
–> wait 12 hrs after a tx dose before resuming proph dose

217
Q

Acute Gout Attack therapy: NSAIDs

A

-Indomethacin (Indocin)
-Naproxen (Aleve)
-Celecoxib (Celebrex)

218
Q

Acute gout attack tx: Steroids

A

-prednisone/Prednisolone
-methylprednisolone

219
Q

Chronic urate lowering therapy: Xanthine oxidase inhibitors

A

-Allopurinol (Zylooprim, Aloprim): SJS.TENs reaction, SE: acute gout attack
-Febuxostat (Uloric) BBW: cardiovascular disease

NAPLEX BABY (23 decks)

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